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Pulse 2018 review: Cash incentives targeted at GPs who cut referrals

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In February, Pulse exposed controversial plans to offer GPs cash incentives for cutting back on patient referrals to secondary care.

The ‘Cash for Cuts’ investigation revealed that in some parts of the country, CCGs were offering money in return for referring fewer patients, in a bid to relieve pressure on secondary care in those areas.

Pulse received 181 CCG responses to freedom of information requests as part of the investigation. One quarter said they offered some kind of financial inducement for reducing referrals to specialists.

Eleven CCGs were paying practices that meet specific referral-cutting targets. In other words, some GPs are being incentivised for not referring their patients.

‘Profit share’ arrangements were up for grabs across five CCGs, which offered practices up to 50% of the savings derived when GPs curb referral activity.

Among other highly contentious and ‘unsafe’ incentives was an NHS Barnsley CCG scheme, worth £1.4m, in which practices that slashed referrals to a handful of specialisms by 10% or more were paid £5 per patient.

GP leaders – unsurprisingly – vociferously criticised such schemes.

Dr Peter Swinyard, chair of the Family Doctor Association, echoed the views of colleagues and peers when he called financial incentivisation a ‘serious dereliction of duty’. In a patient’s eyes, ‘it means GPs are paid to not look after them’, he added.

Not only are cash incentives for reducing referrals ethically questionable, but there is no evidence they actually work.

Granted, these schemes may result in fewer unnecessary referrals. But referrals that are needed – patients who really do require specialist consultation or treatment – could well be the collateral damage.

Coinciding with Pulse’s investigation, the RCGP published a review into referral management centres that are set up by CCGs to reduce GP referrals to secondary care.

It stated these centres were not demonstrably safe or cost-effective, undermine GPs, and erode patient trust - and called for them to be scrapped.

But despite the outcry back in February, come autumn most of the CCGs offering profit share schemes in return for fewer hospital referrals looked set to move forward with their plans.

By September, only one of the five had done a U-turn. Three are going ahead in the 2018-19 financial year, while one CCG was still reviewing arrangements.

And while cash for referral cuts may ease some strain on hospital services, the consequence for GPs is yet more stress, which they could well do without.

Readers' comments (6)

  • Reading this article raises a number of alarm bells. Firstly, and the one the government, medical directors and regulators bang on about.....PATIENT SAFETY!!!

    Part of the problem with this, is the micro-managing approach to trying to reduce NHS expenditure. While the GP training curriculum and examinations have become more detailed and extensive, the question arises as to whether this has translated into better care? I would welcome statistics from my general practitioner colleagues on this area. A significant bulk of general practice work is related to chronic disease management. As a hospital doctor I can state that this is something GPs do very well, provided they follow guidelines. The question arises then, is what exactly are the GPs referring? Also which practices are referring more? If they are referring more, is that influenced by other factors such as patient education level, economic deprivation etc. The list is long when looking at factors that influence the referrals. Having established that, is there an evidence based approach where they can be managed more cost effectively? Also has the dumbing down of Public Health coincided with problems in the management system?

    I would be interested to see if this approach has led to more harm to patient care? If this does occur, is this due to lack of knowledge and expertise of the GP?

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  • Watched ‘Jamie and Jimmy’s Friday Night Feast’ a couple of evenings ago (it can be jolly entertaining). Anyway, they came up with the brilliant idea of how the public’s health problems could be resolved by making ‘Nutrition’ a compulsory part of medical education (not sure whether the course on nutrition would be fit-in before or after the courses on ‘central heating boiler maintenance’, ‘sky diving documentation’ etc?
    To be fair to J&J, there is a surplus of ‘popcorn’ in medical management discourse.

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  • Within the past four years I reduced my referrals and prescribing to just a third of what they were! Also admissions by the same amount!
    I did this by cutting my weekly sessions down from six to just two. Where do I claim my reward?

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  • Burnt out 6:10pm Brilliant -- upiu nailed it.
    The more we see the more crap we prescribe and the more we refer.
    More SSRIs anyone?

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  • doctordog.

    Will the cash be enough to offset the increase in litigations for treatment delays?

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  • Can someone please report these CCGs to the GMC please. Oh wait the GMC doesn't care about bonified cases of patient safety.

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